Current through Reg. 49, No. 38; September 20, 2024
(a) The total
maximum allowable reimbursement (MAR) for a maximum medical improvement (MMI)
or impairment rating (IR) examination is equal to the MMI evaluation
reimbursement plus the reimbursement for the body area or areas evaluated for
the assignment of an IR. The MMI or IR examination must include:
(1) the examination;
(2) consultation with the injured
employee;
(3) review of the records
and films;
(4) the preparation and
submission of reports (including the narrative report and responding to the
need for further clarification, explanation, or reconsideration), calculation
tables, figures, and worksheets; and
(5) tests used to assign the IR, as outlined
in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), as
stated in the Labor Code and Chapter 130 of this title.
(b) Treating doctors must only bill and be
reimbursed for an MMI and IR examination if they are an authorized doctor in
accordance with the Labor Code and Chapter 130 and §
180.23 of this title.
(1) If the treating doctor determines that
MMI has not been reached, the treating doctor must bill, and the insurance
carrier must reimburse, the MMI evaluation portion of the examination in
accordance with subsection (c)(1) and (2) of this section.
(2) If the treating doctor determines MMI has
been reached and there is no permanent impairment because the injury was
sufficiently minor, an IR evaluation is not warranted and the treating doctor
must bill, and the insurance carrier must reimburse, only the MMI evaluation
portion of the examination in accordance with subsection (c)(1) and (2) of this
section.
(3) If the treating doctor
determines MMI has been reached and an IR evaluation is performed, the treating
doctor must bill, and the insurance carrier must reimburse, both the MMI
evaluation and the IR evaluation portions of the examination in accordance with
subsection (c) of this section.
(4)
If the treating doctor is not authorized to assign an IR, the treating doctor
may refer the injured employee to an authorized doctor for the examination and
certification of MMI and IR. The referred doctor must bill under §
134.260 of this chapter.
(c) The following applies for
billing and reimbursement of an MMI or IR evaluation by a treating doctor.
(1) CPT code. The treating doctor must bill
using CPT code 99455 with the appropriate modifier. Modifiers "V3," "V4," or
"V5" must be added to CPT code 99455 to correspond with the last digit of the
applicable office visit.
(2) MMI.
MMI evaluations must be reimbursed based on the applicable established patient
office visit level associated with the examination under §
134.203 of this chapter.
(3) IR. For IR examinations, the treating
doctor must bill, and the insurance carrier must reimburse, the components of
the IR evaluation. Indicate the number of body areas rated in the units column
of the billing form.
(A) For musculoskeletal
body areas, the treating doctor may bill for a maximum of three body areas.
(i) Musculoskeletal body areas are:
(I) spine and pelvis;
(II) upper extremities and hands;
and
(III) lower extremities
(including feet).
(ii)
For musculoskeletal body areas:
(I) the
reimbursement for the first musculoskeletal body area is $385 adjusted per
§134.210(b)(4); and
(II) the
reimbursement for each additional musculoskeletal body area is $192 adjusted
per §134.210(b)(4)
(B) For non-musculoskeletal body areas, the
treating doctor must bill, and the insurance carrier must reimburse, for each
non-musculoskeletal body area examined.
(i)
Non-musculoskeletal body areas are defined as follows:
(I) body systems;
(II) body structures (including skin);
and
(III) mental and behavioral
disorders.
(ii) For a
complete list of body system and body structure non-musculoskeletal body areas,
refer to the appropriate AMA Guides.
(iii) The reimbursement for the assignment of
an IR in a non-musculoskeletal body area is $192 adjusted per
§134.210(b)(4)
(d) If the examination for the determination
of MMI or the assignment of IR requires testing that is not outlined in the AMA
Guides, the treating doctor must bill, and the insurance carrier must
reimburse, the appropriate testing CPT code or codes according to the
applicable fee guideline in addition to the fees for the examination by the
treating doctor outlined in subsection (c) of this section.
(e) The treating doctor is required to review
the certification of MMI and assignment of IR performed by another doctor, as
stated in the Labor Code and Chapter 130 of this title. The treating doctor
must bill using CPT code 99455 with modifier "VR" to indicate a review of the
report only, and the insurance carrier must reimburse $64 adjusted per
§134.210(b)(4).
